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Clinical Prediction Rules Versus PSGThirteen studies (102, 144, 157–167) assessed a total

of 16 internally validated clinical prediction rules (refer tothe AHRQ report [28] and the Supplement for descrip-tions of each of these tools). Most of the rules used infor-mation that was available through clinical history and ex-amination, and all were compared with facility-based PSG.Studies were highly heterogeneous with respect to popula-tions assessed, type of reference test used, and OSA defini-tions, and only 1 study was identified for each predictionrule. Overall, low-quality evidence suggested that someclinical prediction rules can be used to effectively predictOSA diagnosis. However, the applicability of these rules tothe general population cannot be determined from the ex-isting literature. In addition, none of the studies examinedthe potential clinical utility of applying these rules to clin-ical practice.Comparison of Phased Testing Versus Full Testing

Phased testing involves a series of tests that may bedone depending on the results of initial tests, whereas fulltesting involves overnight PSG. Evidence was insufficientto determine the utility of phased testing for diagnosingOSA; 1 low-quality prospective study was subject to veri-fication bias (168), and another reported a positive likeli-hood ratio of at least 3.9 and a negative likelihood ratio of0.06 (102).

PREDICTORS OF LONG-TERM CLINICAL AND

FUNCTIONAL OUTCOMES

Fourteen studies met the inclusion criteria for predic-tors of long-term clinical outcomes, such as mortality,stroke, hypertension, and cardiovascular disease (5, 10, 19,20, 169–178). Results were inconclusive to establish acausal relationship and are summarized in Table 4.

SUMMARY

Polysomnography performed in a sleep laboratory hasbeen the standard method to diagnose OSA; however, itrequires specialized facilities, is resource-intensive and ex-pensive, and requires patients to spend the night underobservation in a foreign environment. In addition to PSG,

portable monitors (types II, III, and IV) can be used todiagnose OSA, although the measured AHI score can differsubstantially from that measured with PSG. Low-qualityevidence showed that type II monitors may identify AHIscores suggestive of OSA. No study directly compared dif-ferent portable monitors with each other, although currentevidence supports greater diagnostic accuracy with type IIImonitors than type IV monitors (28). The utility of por-table monitors for diagnosing OSA in patients with comor-bid conditions, including chronic lung disease, congestiveheart failure, or neurologic disorders, is uncertain becausemost studies excluded these patients. Also, compared withPSG, type II, III, and IV monitors had a wide range ofdifference in AHI estimates (28).

A significant limitation of type IV monitors is thatthey cannot differentiate between obstructive and centralapneas. In contrast to OSA, where airflow is disrupted be-cause of airway obstruction, central sleep apnea resultsfrom a temporary failure of the brain to send signals tobreathe. Because CPAP may be contraindicated in patientswith central sleep apnea, an accurate diagnosis is impor-tant. Patients with cardiac, respiratory, or neurologic dis-ease may be at the greatest risk for central sleep apnea, andthe AASM does not recommend the use of portable mon-itors for diagnosis in these patients (179).

Although the evidence was insufficient to determinethe utility of most questionnaires compared with PSG forOSA screening, low-quality evidence indicated that theBerlin Questionnaire may be used to screen for OSA.However, questionnaires may not be applicable to the gen-eral population because they include subjective questionsabout sleepiness and not all patients, even those with severeOSA, report sleepiness. For example, the Wisconsin SleepCohort Study found that only 37% of patients with severeOSA (AHI score !30 events/h) reported daytime sleepi-ness and that mortality associated with long-term OSA wasindependent of subjective sleepiness (20).

Evidence was insufficient to determine the effective-ness of phased testing for the diagnosis of OSA or theutility of preoperative screening for OSA to improve post-surgical outcomes.

Table 4. The AHI as a Predictor of Clinical Outcomes

Outcome Evidence Overall Qualityof Evidence

Reference

All-cause mortality Association with increased risk with AHI score !30 events/h High 19, 20, 171, 172, 176Cardiovascular mortality Inconsistent results Insufficient 5, 20Nonfatal cardiovascular disease Association with increased risk with AHI score !30 events/h and no

CPAP treatmentInsufficient 5, 177

Stroke No association Insufficient 169Hypertension Unclear conclusions Insufficient 10, 173, 178Type 2 diabetes Association with increased risk with AHI score !30 events/h Low 170, 174Quality of life No association Insufficient 175

AHI " apnea–hypopnea index; CPAP " continuous positive airway pressure.

Clinical GuidelineDiagnosis of Obstructive Sleep Apnea in Adults

www.annals.org 5 August 2014 Annals of Internal Medicine Volume 161 • Number 3 213

Downloaded From: http://annals.org/ by Tsukuba University Library, Hiroki Isono on 10/15/2014

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